Doula Client Intake FormPlease fill out the following form to get started with Douly Yours services. Client Information Name * First Name Last Name Partner's Name First Name Last Name Due Date * MM DD YYYY Address Address 1 Address 2 City State/Province Zip/Postal Code Country Phone (###) ### #### Email * Healthcare Provider * Place of Birth (City, State, County) * Prior Pregnancy and/or Birth Experiences (skip if non-applicable) Total number of pregnancies (including this one) History of fetal or infant loss? Yes No Have you experienced any complications with pregnancy? Yes No # of previous vaginal deliveries # of cesarean births How did each of your labors begin? Did previous births happen before, on or after your due date? Length of time for labor(s)? Did you experience any complications during labor or birth? Prior Breastfeeding Experience (skip if non-applicable) Have you breastfed before? Yes No Did you have a positive breastfeeding experience? Yes No Do you plan to breastfeed now? Yes No Preparation for Birth What childbirth class have you or will you attend? Are you currently experiencing any specific health or other concerns that affect this pregnancy? How do you see the role of your doula? During labor and birth, emotions associated with prior sexual abuse can come to the surface. As your support, it may be helpful for me to be aware if this issue exists and what your triggers are or may be. As with all of your information, any information you share will be kept confidential. Thank you!
